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Orthodontic insight

Advancements in the knowledge of


induced tooth movement: Idiopathic osteosclerosis,
cortical bone and orthodontic movement
Alberto Consolaro1, Renata Bianco Consolaro2

Moving teeth orthodontically through the dense trabecular bone and cortical areas may require a reduction in the
intensity and/or concentration of the applied forces. In part, the orthodontic applied forces are dissipated and reduced by bone deflection, which normally occurs by a slight degree of elasticity of bone tissue in normal conditions.
In areas of dense trabecular and in cortical bone this deflection should be insignificant or nonexistent. If there is no
reduction in the intensity of the forces in these mentioned regions, the entire force will focus on the structure of
the periodontal ligament, increasing the risk of death of cementoblasts, hyalinization and root resorption. Further
studies could assess the prevalence of these consequences in populations selected for this purpose, so that would no
longer be randomly observed notes.
Keywords: Cortical bone. Idiopathic osteosclerosis. Chronic focal sclerosing osteitis [osteomyelitis]. Orthodontic movement. Induced tooth movement.

trabecular bone density, as well as in its cortical thickness and morphology of the bone crest.
This extreme variability, when extreme, may influence significantly in more or less symptoms during orthodontic movement as well as the risk of root resorption.

The orthodontic movement depends on the application of forces to the tooth promoting compression of the periodontal ligament. The deformation
of cells and their cytoskeletons, in addition to the reducing blood flow and hypoxia, lead to cell stress with
increased release of mediators that stimulate bone
resorption in the surface of the periodontal alveolar
bone. Thus, teeth move orthodontically.
In training for the application of orthodontic
forces, it is common to have uniformity in the procedures. However, the bone has a great variability in the

Full Professor, FOB, and Post-Graduation course, FORP - So Paulo University.

PhD Professor, FOA, Unesp and Integrated Adamantinenses School.

Trabecular bone density


The density of trabecular bone varies according
with the skeletal region. In the maxilla, the variability
of the trabecular bone density is large, even when considering different areas of a same maxilla or mandible.

How to cite this article: Consolaro A, Consolaro RB. Advancements in the knowledge of induced tooth movement: Idiopathic osteosclerosis, cortical bone and orthodontic movement. Dental Press J Orthod. 2012 July-Aug;17(4):12-6.
Submitted: March 26, 2012 - Revised and accepted: march 31, 2012

The authors report no commercial, proprietary, or financial interest in the products


or companies described in this article.

2012 Dental Press Journal of Orthodontics

Contact address: Alberto Consolaro


E-mail: consolaro@uol.com.br

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Dental Press J Orthod. 2012 July-Aug;17(4):12-6

insight ortodntico

Avanos no conhecimento da movimentao dentria induzida


Osteoesclerose idioptica, corticais sseas e o
movimento ortodntico
Alberto Consolaro1, Renata Bianco Consolaro2

Movimentar ortodonticamente os dentes por reas densas do trabeculado sseo e pelas corticais pode requerer uma
reduo na intensidade e/ou na concentrao das foras aplicadas. Em parte, as foras ortodnticas aplicadas so
dissipadas e reduzidas pela deflexo ssea que ocorre pelo discreto grau de elasticidade do tecido sseo em condies
de normalidade. Nas reas de trabeculado denso e nas corticais, essa deflexo deve ser irrisria ou inexistente. Se no
houver uma reduo na intensidade das foras nessas regies citadas, toda a fora incidir sobre a estrutura do ligamento periodontal, aumentando o risco de morte dos cementoblastos, hialinizao e reabsores radiculares. Novos
trabalhos poderiam avaliar a prevalncia dessas consequncias em casusticas selecionadas para essa finalidade, que,
assim, deixariam de ser observaes aleatrias.
Palavras-chave: Cortical ssea. Osteoesclerose idioptica. Ostete crnica esclerosante focal. Movimentao
ortodntica. Movimentao dentria induzida.

Professor Titular da FOB e da Ps-graduao da FORP - Universidade de So Paulo.

Professora Doutora Substituta de Patologia da FOA-Unesp e das Faculdades


Adamantinenses Integradas.

Como citar este artigo: Consolaro A, Consolaro RB. Advancements in the knowledge of induced tooth movement: Idiopathic osteosclerosis, cortical bone and orthodontic movement. Dental Press J Orthod. 2012 July-Aug;17(4):12-6.
Enviado em: 26 de maro de 2012 - Revisado e aceito: 31 de maro de 2012
Endereo para correspondncia: Alberto Consolaro
E-mail: consolaro@uol.com.br

Os autores declaram no ter interesses associativos, comerciais, de propriedade ou


financeiros que representem conflito de interesse nos produtos e companhias descritos nesse artigo.

2012 Dental Press Journal of Orthodontics

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Dental Press J Orthod. 2012 July-Aug;17(4):12-6

Consolaro A, Consolaro RB

it tends to assert that it is getting loose, spongy or


yet refers to these as areas of bone rarefaction, by
analogy to thin air. In regions of the mandibular
angle or later the upper and lower third molars,
including the tuberosity of the maxilla, there are
patients with very loose areas or with normal bone
rarefactions.

This variability is related to structural adaptation to


functional demands. The more physical or biologically required, within the normal range, the denser
the trabecular bone will be, the marrow spaces will
become smaller and in greater number in the radio
and tomographic1 images (Figs 1 and 2). The bone
cells work in the remodeling to adequate the tissue
to functional demands by increasing or decreasing
their structures. Thus, the trabeculae may be bigger
or smaller, narrower or wider; thus, the cortical may
increase or decrease its thickness according to the
functional demands required (Figs 1 and 2).
In images, the denser the trabecular bone, we
tend to say that the same is suffering sclerosis.
The term bone sclerosis is usually reserved for the
densest areas of trabecular bone, where it is assumed that passed the normal morphologic limits.2
In some texts sclerosis is used in place of the term
bone condensation.
An area can typically presents with bone as dense
as the anterior region of the mandible, without
which we must call it as it represents a bone sclerosis of trabecular variability given a functional demand. When a certain situation or illness increases
bone density usually adds the terms sclerosing or
condensing to its name, especially for being a pathological nature.
When the trabecular bone present is less dense,

Focal Sclerosing Osteitis versus


Idiopathic Osteosclerosis
The inflammatory osteitis is located, restricted
to focal areas and less aggressive, which may involve
the various components of bone.2 Almost always related to aggressive agents of low intensity and long
duration, such as endodontic and periodontal lesions
(Figs 1 and 2). In chronic periapical lesions a localized inflammation and thin bone in the periapex is
commonly established , and finally an osteitis in
these cases are given specific names such as periapical granuloma, chronic dentoalveolar abscess and
other well-known names. These areas serve for the
thin bone to give way to exudade fluid and cells and
inflammatory infiltrate, respectively.
In bone rarefaction, the causes act directly on
the site, but the adjacent bone receives even smaller stimuli that accumulate the same inflammatory mediators, but in lower concentrations which
reverse the stimulation of resorption to bone

Figure 1 - Focal chronic sclerosing osteitis related to pulp necrosis and chronic periapical lesion, with small and irregular thin bone areas around the root canal opening, with predominant radiopaque images in the surroundings of thin bone areas.

2012 Dental Press Journal of Orthodontics

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Dental Press J Orthod. 2012 July-Aug;17(4):12-6

insight ortodntico

Advancements in the knowledge of induced tooth movement: Idiopathic osteosclerosis, cortical bone and orthodontic movement

even though approximately 30%


of the cases no longer return to
Ob
normal. In other words, with root
canal therapy, dental extraction,
periodontal treatment or any
MS
other therapeutic approach, a
focal sclerotic bone area may inAP
definitely remain in that place.2
After a few months or years, with
remodeling and morphological
upgrading of the site, without a
Oc
prior well documented history
(Fig 3), it will be very difficult to
understand or identify any cause
Figure 2 - Focal chronic sclerosing osteitis, demonstrating reduction of the medullary space (MS)
that induced that abandoned
filled in by conjunctive tissue with a discreet and difuse mononuclear infiltrate. The trabeculae are
thick, with well defined layers of apposition (AP). Ob=osteoblasts; Oc=osteoclastas. (HE, 25x).
focal sclerotic bone area.
The term Idiopathic Osteosclerosis also known as Dense Bone
Isle or simply Focal Idiopathic Bone Sclerosis is the
formation (Figs 1 and 2). The adjacent bone thereby
most commonly used to identify focal sclerotic areas withincrease its density and suffers sclerosis. The osteitis, as a whole, starts to present several sclerotic arout identifying the cause-effect relationship (Fig 3). They
are irregular and located radiopaque areas which contineas around the rarefact area.2 In most affected cases
radiopaque or neighboring dense areas predominate
ue naturally with the surrounding trabeculae without any
in the overall image of the process. In these cases the
line or radiolucent halo in outline or limit. The presence
lesion is now diagnosed as Chronic Focal Sclerosing
of a radiolucent halo indicates a fibrous capsule, which is
Osteitis. In some texts and reports it can be named as
typical of neoplastic diseases such as Fibrodysplasia OssiChronic Focal Condensing Osteitis. The term focal
ficans, osteomas, and odontomas, for example.
can often be replaced by the term local.
The Idiopathic Osteosclerosis without an idenIf the cause of Chronic Focal Sclerosing Osteitis
tifiable cause, may have been earlier a Chronic Fois removed the inflammation process disappears,
cal Sclerosing Osteitis with defined cause which
and, in general, the region remains indefinitely with
was eliminated, but without documentation of their
a bone sclerosis which will be reshaped with time,
previous history it is impossible to make definitive

Figure 3 - Idiopathic Osteosclerosis (arrows) without cause-effect identification. In the past, some low intensity and long duration trauma may have happened in the
area. The sclerotic areas persisted indefinitely and, very slowly, can disappear with constant and normal bone remodeling.

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Consolaro A, Consolaro RB

statements. In many cases, the cause may be related


to primary teeth with inter-radicular lesions, occlusal trauma, chronic periapical diseases, repair of
bone surgery procedures that were used as autogenous bone grafting and other procedures.
The bone in an Idiopathic Osteosclerosis has
structure and normal function, the difference is in
the higher trabecular density. In this region teeth
can be moved, osseointegrating implants and mini
implants can be applied without further consequences, as long as in the region there is no infectious microbial component.

absence of cells by their escape into the surrounding areas and/or their death. If this happens, the
segment of the periodontal ligament will be amorphous and eosinophilic, occupied only by hyalinized extracellular matrix. With intense or concentrated forces tooth movement does not occur. If it
occurs, it can only minimally be moved, but taking
longer and at the expense of many symptoms and
root resorption.1
For an orthodontic movement to be effective, it
requires a biologically viable association, with preserved cells and tissue components. The orthodontic movement represents an event of biological and
not physical nature; forces are the initial inducing
agents of biological processes. When applying great
or concentrated forces cellular life on the region is
prevented and orthodontic movement to occur requires cells and vessels functioning normally.
When you apply an orthodontic force in teeth
inserted or neighboring areas of thicker bone, the
deflection is insignificant or absent.1 The force applied on the tooth tends to focus on its full potential on the periodontal ligament, which contains the
cementoblasts, which protect the integrity of root.
Hyalinization areas may be established by leakage
and cell death, despite conventional orthodontic
forces applied. Without the deflection due to the
higher bone density, normal and conventional forces become dangerous to the tissue ligament during
tooth movement along areas of idiopathic osteosclerosis. Any force applied to teeth in dense areas,
directly affect the periodontal ligament.
In cases needing to move a teeth through denser areas such as idiopathic osteosclerosis bone
type, the ideal would be to use smaller forces than
those conventionally employed, compensating
part of the force that would be dissipated by the
adjacent bone deflection. By analogy, reducing the
force corresponds to a discount, or compensation,
because the bone deflection does not happen due
to the higher density on site. In doing so, surprisingly a normal and even faster movement will occur, even in a denser area.
The same reasoning on force application in the
orthodontic movement having part of their intensity dissipated by bone structures around the teeth
can be extrapolated to the cortical bone (Fig 4).

Specific care for tooth movement


into sclerotic areas
In idiopathic osteosclerosis, the cells and other
bone structures are normal. Remodeling is done
normally, but takes longer, because as the trabeculae are thicker and the medullary spaces are very
small, there are fewer surfaces exposed to the activity of the clasts. The more cancellous is the bone;
more available surfaces are suitable for the action
of the cells in bone remodeling units, especially the
clasts, by allowing a faster process. In areas of Idiopathic Osteosclerosis, remodeling or turnover happens in a slower pace, as occurs in the cortex when
compared with the trabecular bone.
The forces in orthodontic movement induce a
bone deflection, a structural deformation that absorbs a small part of the applied force, reducing the
effects on the periodontal ligament. Specifically, in
the periodontal ligament, most of the applied forces
are imposed on the vessels and cells, with stress,
releasing and increasing the concentration of mediators required for the alveolar bone resorption for
tooth movement to occur.
The integrity of the periodontal ligament and
their cells is very important for tooth movement to
occur. If the force completely blocks the lumen of
blood vessels, anoxia causes the cells to migrate or
die, leaving at the site only the hyaline extracellular
matrix and the movement does not occur efficiently
and significant root resorption, due to the death of
cementoblasts, can still happen.1
In the orthodontic movement, the greater or
more concentrated is the force, the more likely
it will not be efficient, because it will promote an

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Dental Press J Orthod. 2012 July-Aug;17(4):12-6

insight ortodntico

Advancements in the knowledge of induced tooth movement: Idiopathic osteosclerosis, cortical bone and orthodontic movement

By moving teeth along cortical


bone, if there is no special care
to reduce force intensity, tooth
displacement may occur, but
Ob
the risk of further destruction
of cementoblasts increases conMS
siderably, with the possibility
of having more severe root resorption.1 In short, when movAP
ing teeth along cortical bone
care should be taken to reduce
Oc
the intensity of the forces, because the bone deflection will
be much smaller, increasing the
effects on the periodontal ligaFigure 4 - Bone cortex constituted by various well defined layers of lamelar aposition (AP), which, in between, osteocytes can be noted. Ob=osteoblasts; Oc= osteoclasts. (HE, 25x).
ment and its structures.
Some questions could be anocclusal trauma. A considerable number of induced
swered in future works:
sclerotic areas takes years or no longer return to nor1) What is the prevalence of root resorption in
teeth that were moved into areas of denser
mal, remaining indefinitely as part of the trabecular
bone, as Idiopathic Osteosclerosis, with and
region, being diagnosed as idiopathic osteosclerosis.
without the care mentioned earlier?
While moving the teeth in these areas force inten2) What is the prevalence of root resorption in
sity should be reduced because they do not exhibit any
teeth that were orthodontically moved along
bone deflection and the same intensity will be applied
denser cortical bone, or even teeth that were
on the periodontal ligament. The use of conventional
anchored in the cortex?
forces in these cases can induce hyalinization areas
3) Would differences in the frequency of root reand death of cementoblasts followed by root resorption, besides preventing an efficient tooth movement,
sorption in some types of teeth be related to
which will become slower and symptomatic.
bone density and the thickness of the cortiThe same extrapolation can be done for tooth
cal bone, features which vary in the different
movement along cortical bone: They have insignifisegments of the jaws?
cant or even no deflection, thus it may increase the
Final Thoughts
risk of root resorption, including when teeth anIdiopathic osteosclerosis has no detectable
chorage is performed in these structures. Further
cause-effect relationship, but may have been an
studies may detect more accurately the prevalence
earlier a Chronic Focal Sclerosing Osteitis, whose
of root resorption, symptoms and efficiency of orthcause has been eliminated, such as a chronic periapiodontic movement when in dense areas of trabecular and/or cortical bone.
cal lesion, periodontal disease, pericoronaritis and

References

1.

Consolaro A. Reabsores dentrias nas especialidades clnicas. 3a ed. Maring


(PR): Dental Press International; 2012.

2.

Wood NK, Goaz PW. Diagnstico diferencial das leses bucais. 2a ed. Rio de
Janeiro: Guanabara Koogan; 1983.

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Dental Press J Orthod. 2012 July-Aug;17(4):12-6

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